Provider Demographics
NPI:1821987934
Name:INITIA NOVA DELAWARE LLC
Entity type:Organization
Organization Name:INITIA NOVA DELAWARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:III
Authorized Official - Credentials:DO, MS
Authorized Official - Phone:302-256-0927
Mailing Address - Street 1:3512 SILVERSIDE RD STE 13
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-4913
Mailing Address - Country:US
Mailing Address - Phone:302-256-0927
Mailing Address - Fax:
Practice Address - Street 1:3512 SILVERSIDE RD STE 13
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-4913
Practice Address - Country:US
Practice Address - Phone:302-256-0927
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-02
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty